Chapter 50: Organ Donation from Trauma Patients

Solid organ transplantation remains the only lifesaving option for an increasing number of patients. Transplantation is now the treatment of choice for end-stage kidney, liver, pancreas, heart, lung, and intestine failure patients who have no contraindications to transplantation. In addition, there is an increasing demand for bone, skin, and other tissues from brain dead donors used in the treatment of other disease processes. However, the number of people requiring organ transplants is simply higher than the number of organs available. Newer approaches such as xenotransplantation and bioengineering are still in experimental stages,¹ and despite advances in living-related solid organ transplantation the majority of transplant recipients remain dependent on cadaveric organ donors. With improved supportive care for patients with advanced organ failure and expanded indications for transplantation the gap between demand and supply of organs is continually increasing (Fig. 50-1). Every 10 minutes, someone is added to the national transplant waiting list and on average, 21 people die each day while waiting for a transplant [http://optn.transplant.hrsa.gov]. Currently in the United States, there are 123,337 patients active on the waiting list. In the year 2014, a total of 29,533 solid organ transplants were performed from 14,412 donors, of whom 8594 were deceased donors and 5818 were living donors. One promising strategy to decrease the gap between the organ donation need and supply is to increase the available donor pool. It is estimated that the actual number of donors in the United States represents about one-third of the potential number of donors, and there certainly is room for improvement.²

Traumatic brain injury is the second most common cause of death leading to cadaveric solid organ donation closely following cerebrovascular accidents/stroke (Fig. 50-2). Clinicians caring for severely injured patients play a key role in the initiation and implementation of the organ donation process. Early recognition of potential organ donors is critical to maximizing the available pool of donor organs and the number of transplantable organs per donor. It is essential for those caring for potential organ donors to be knowledgeable about the criteria and process for declaring brain death and the physiologic effects of brain death. Familiarity with local organ procurement organizations (OPOs) is important because of the vital role they play in counseling the families of potential organ donors and coordinating the transplant process. Lastly, following the declaration of brain death, treatment priorities aimed at minimizing brain injury require adjustment. Physiologic support is then directed at maintaining perfusion of potentially transplantable organs assumes priority, and timely initiation of this support is crucial to increasing the probability of successful transplantation.

Under the National Organ Transplant Act, the US Congress established The Organ Procurement and Transplantation Network (OPTN). The OPTN is a unique public–private partnership linking professionals involved in the organ donation and transplantation system. The OPTN is governed by the United Network for Organ Sharing (UNOS). UNOS is a private nonprofit charitable organization contracted by the Health Resources and Services Administration of the US. Department of Health and Human Services (DHHSs) to develop organ transplantation policy. UNOS facilitates organ transplantation by organizing the medical, scientific, public policy, and technologic resources required to maintain an efficient national transplantation system. UNOS is responsible for developing recipient priority policies and for managing the national transplant waiting lists. UNOS maintains the national transplant database; plays a very important role in raising public awareness of the importance of organ donation, and helps to keep patients informed about transplant issues and policy.

To alleviate the shortage of organs available for transplantation, the Revised Uniform Anatomical Gift Act requires OPOs and donor hospitals to have the necessary policies and procedures in place to preserve the option of donation for all patients and their families.⁴ In an effort to maximize donation opportunities, the American College of Surgeons (ACS) qualitatively evaluates each hospital’s organ donation practices during the trauma center verification process.⁵ Specifically, the ACS requires verified trauma centers to establish a relationship with an OPO; develop policies and clinical triggers for notification of the OPO about patients with the potential for neurologic death; have a formal process to review organ donation rates; and implement protocols for the declaration of neurologic death. Organ donation, allocation, and procurement require a closely coordinated and complex series of efforts. In the United States, this process is coordinated by independent local OPOs. There are 58 OPOs in the United States. OPOs are responsible for two main functions within their designated service area: (1) increasing the number of registered donors, and (2) coordinating the donation process when actual donors become available. OPOs employ specially trained professionals who assist with the evaluation of potential organ donors, the declaration of brain death, counseling of donor family members, management of the donor, organ allocation, and the procurement process. When an organ donor is identified, the local OPO serves to ensure that brain death has been established and assists in obtaining consent for organ donation. Thereafter, coordination of organ placement and the procurement of the organs are facilitated by the OPO. For organ allocation, UNOS maintains a centralized computer network, UNet, which links all OPOs and transplant centers in a secure, real-time environment using the Internet. Each organ waiting list incorporates specific criteria to establish individual patient ranking on the list. However, in general, waiting lists incorporate factors such as geography, patient’s blood type, waiting time, severity of illness and human lymphocyte antigen (HLA) matching in case of kidney allocation.

Trauma surgeons play important role in organ donation. It has been shown that hospitals with trauma surgeons on their organ donor councils had a significantly higher number of donors per trauma admissions as well as significantly more donors per admissions.⁶

UNOS has developed “The Critical Pathway” for management of organ donors, which is available through local OPOs and UNOS.⁷ Preliminary data from a pilot study utilizing this pathway showed an increase in the number of organs procured per donor. The Critical Pathway has five distinct but partially overlapping phases:

• Phase I (referral): When a patient with a severe brain injury is identified as a potential organ donor, critical care staff should initiate the Critical Pathway. This initial step establishes contact between the hospital and the local OPO, and initiates referral before the potential organ donor becomes brain dead.

• Phase II (declaration of brain death and acquisition of consent): Once the potential donor is confirmed brain dead, the patient’s choice about organ donation is evaluated through the donor registry (usually through the motor vehicle registry) and the family is provided with this information. If no first person consent is found, the family is approached about the option of organ donation. First person consent supersedes a family declining the option of donation in many states and OPOs in the US.

• Phase III (donor evaluation): After consent for organ donation is obtained or confirmed through a donor registry, donor evaluation and management protocols are initiated.

• Phase IV (donor management): As the donor is being evaluated, optimal management needs to be started simultaneously to achieve adequate perfusion and oxygenation of organs.

• Phase V (organ recovery): Organ procurement takes place after potential recipients are identified. Various procurement teams work together to maximize organ recovery.

Federal law requires that every death in a hospital be called in to respective OPO, and the OPO coordinators evaluate every call to assess suitability for donation. All patients who have suffered severe brain injuries and are either brain dead or likely to progress to brain death should be considered for organ donation regardless of their age, underlying cause of illness, and overall social history.

According to CMS, hospitals and respective OPOs must agree upon “triggers” to identify potential brain dead donors, although CMS does not specify these “triggers.” For instance some OPOs consider an intubated patient with a GCS of five or less a potential organ donor. If a patient meets initial criteria, the donation case moves on to the next step in the process, which is referral to the local OPO. Although perceived contraindications to donation may exist, they should be discussed with a representative of the local OPO before concluding that a given patient is not a candidate for organ donation (Table 50-1). Bacteremia, fungemia and high-risk social history are not absolute contraindications. For increased-risk donors, nucleic acid test (NAT) is performed to detect recently acquired HIV, HCV, and HBV infections wherein routine serology tests are negative. Sometimes, donors with HCV, HBV, and HIV are considered suitable for organ donation. For instance, an otherwise normal liver or a kidney from a donor with HCV infection can be transplanted into HCV infected recipient. Trauma to chest and/or abdomen is not uncommon in potential organ donors. Appropriate surgical management is required to control bleeding and prevent complications such as pneumothorax. Typical interventions include chest tube insertion, laparotomy, splenectomy etc. Retroperitoneal hematoma, liver and splenic lacerations, open abdomen are not contraindications to abdominal organ utilization; however such circumstances demand careful evaluation of organs at the time of procurement. A CT scan utilizing intravenous contrast is important in assessment of severity of injury and vascular integrity.

The physician caring for potential organ donor is responsible for notifying the local OPO of such patients. All OPOs employ personnel who are responsible for advising health care providers on the suitability of an individual patient for organ donation. Communication with local forensic authorities is extremely important. The OPO will contact the medical examiner or coroner in order to obtain permission to proceed with organ donation. Once a donor is identified, the OPO is responsible for obtaining family consent for organ donation. Organ procurement specialists are trained in counseling families about the importance and process of organ donation, and it is advisable to refer families to these specialists when potential organ donation is discussed. These individuals also perform a careful review of the potential donor’s social and past medical history. The circumstances leading to brain death are very important, as is any history of the occurrence and duration of cardiopulmonary arrest. Screening also includes an extensive laboratory and serologic evaluation to exclude chronic disease and transmissible infections. A donor profile is then generated and includes current hemodynamics as well as an assessment of current organ function. The assessment of organ function is individualized to the donor based on the donor profile, the specific organs under consideration, and the level of medical support required to maintain the donor. The overall profile that is generated is crucial for transplant physicians who must evaluate the suitability of a given organ donor for the individual recipient.

Brain death occurs when a person has an irreversible, catastrophic brain injury, which causes total cessation of brain function. Some causes of brain death include (but are not limited to): (1) trauma to the brain (ie, severe head injury caused by a motor vehicle crash, gunshot wound, fall or blow to the head), (2) cerebrovascular accident (ie, stroke or rupture of an aneurysm), (3) anoxia (ie, respiratory arrest, drowning), and (4) brain tumor. Ethical standards in the United States mandate that all organ donors must be declared dead before organ donation can proceed. Brain death must therefore constitute a sufficient basis on which to declare a person legally dead. The vast majority of cadaveric organs are procured from donors whose deaths are declared on the basis of brain death. Consequently, cadaveric organ donation is dependent on the ability to reliably determine that a patient is brain dead. Unfortunately, many clinicians remain poorly informed about brain death and how it is defined. The current concept of brain death used in the United States is based on guidelines published in 1981 by the President’s Commission for the Study of Ethical Problems and adopted under the Uniform Determination of Death Act (Table 50-2).⁸ This act states that death has occurred when there is irreversible cessation of all functions of the brain including the brain stem. Each state government has adopted these guidelines in legislating local criteria for the determination of brain death. The qualifications and number of physicians who must agree on the diagnosis of brain death in order to legally declare a patient brain dead vary considerably among different states. Some states require two separate declaration procedures with a defined time interval between the two examinations. Some states require that two separate physicians make the declaration. In other states a single physician may declare a patient brain dead on the basis of one examination. In no case can the declaring physician take part in the recovery or transplantation of organs from the donor. Most hospitals have established policies within state guidelines for physician qualifications required to make the diagnosis of brain death. Physicians caring for these patients should be aware of local requirements and hospital guidelines in order to facilitate the declaration process and allow termination of care for brain dead patients who will not be organ donors.

Symptoms that support the diagnosis of brain death are the absence of brain stem reflexes, absence of cortical activity, and the demonstration of the irreversibility of this state.⁹ Therefore, in order to declare brain death there must be a proof of the cause of brain injury; otherwise, the irreversibility requirement cannot be met. Secondly, all reversible causes of coma must be excluded. Causes of reversible coma include hypothermia, hypoxia, hypoglycemia, hyperglycemia, uremia, hepatic failure, Reye’s syndrome, hyponatremia, hypercalcemia, myxedema, adrenal failure, and central nervous system (CNS) depressants. The presence of CNS depressing agents such as narcotics, sedatives, anticonvulsants, anesthetics, and alcohol must be assessed. If any of these agents are present, confirmatory testing is usually required to declare brain death.¹⁰ In the brain dead patient, all cranial nerve functions will be absent. The absence of brain stem reflexes must be confirmed by careful neurologic examination. Neuromuscular conduction must be intact in order to allow adequate examination; consequently, the presence of neuromuscular blocking agents must be excluded.

The most definitive finding supporting the diagnosis of brain death is the presence of apnea. The apnea test remains one of the most important parts of the neurologic evaluation of potential organ donors.¹¹ To perform a reliable apnea test the Pa^CO₂ is normalized to 40 mm Hg. The patient is preoxygenated with 100% O₂ for at least 5 minutes. The patient is then disconnected from the ventilator and placed on 100% O₂ delivered passively to the endotracheal tube via a T-piece at 8–12 L/min. The Pa^CO₂ is allowed to rise to 60 mm Hg, confirmed by a blood gas drawn after approximately 10 minutes. If hemodynamic instability occurs, the patient should be immediately returned to mechanical ventilation and a blood gas should be drawn to assess the Pa^CO₂. If there is any evidence of respiratory activity, the patient is not brain dead and should be immediately returned to the ventilator. If there is no evidence of spontaneous respiratory activity, the Pa^CO₂ has reached 60 mm Hg, and the pH is acidotic, apnea is established and is strongly supportive of brain death.

In many cases confirmatory testing must be performed in addition to a careful neurologic examination in order to firmly establish the diagnosis of brain death. Patients with cervical fractures above the level of C4 may not have intact diaphragmatic function precluding a reliable apnea test. Apnea testing is also unreliable in cases involving overdoses of substances that depress respiratory drive such as alcohol, antiseizure medications, and sedatives. Hemodynamic instability during apnea testing will also preclude the establishment of the diagnosis of brain death on the basis of apnea. In other cases local requirements and or hospital policy may dictate the use of additional confirmatory testing. Confirmatory tests may also be useful in demonstrating a clear etiology for brain death or severe anatomic damage and can decrease the observation period required to establish the diagnosis of brain death.¹⁰

Confirmatory tests of brain death include electroencephalogram (EEG) and methods of demonstrating the absence of cerebral blood flow. EEGs are not entirely reliable and are now rarely used for this purpose with the exception of brain death determination in young infants. Demonstration of the absence of cerebral blood flow is the most common confirmatory test currently in use. Methods used to make this determination include cerebral angiography, Doppler ultrasound scanning, and radionuclide cerebral blood flow scanning. The latter two methods are noninvasive, low risk, relatively inexpensive, and are more readily available than cerebral angiography. These tests are highly accurate in verifying the absence of cerebral blood flow and are useful in reducing the time required to establish the diagnosis of brain death. Conversely, an examination that indicates continued cerebral blood flow does not necessarily exclude the diagnosis of brain death. Uncommonly, cerebral blood flow may persist despite brain death due to testing before increasing intracranial pressure completely shuts down flow, skull pliability in infancy or in the presence of decompressing fractures, ventricular shunts, ineffective deep brain flow, reperfusion, brain herniation, jugular reflux, the presence of emissary veins, and pressure injection artifacts.¹²

Appropriate documentation of brain death is very important in facilitating organ donation for a brain dead patient. The diagnosis of brain death must be documented in writing and it must be unequivocal. The circumstances leading to brain injury, the specific findings of the neurologic examination, and the results of any confirmatory tests should be clearly recorded. Lastly, the date and time of the declaration of brain death must be noted before OPO personnel may obtain the permission of local authorities and the consent of the potential donor’s family. Despite the presence of evidence indicating a person’s desire to be an organ donor, family consent for donation must be obtained. Family refusal is the most common reason that otherwise suitable donors do not become organ donors. If consent for donation is declined, appropriate testing and documentation of brain death is necessary in order to initiate the withdrawal of care.

In some patients with catastrophic brain injury the intracranial pressure (ICP) is maintained and brain death does not occur. However in these patients, the severity of neurologic injury is such the no recovery is expected. Such patients, regardless of the disease process, may be considered for withdrawal of life support because of a hopeless prognosis and for donation after cardiac death (DCD) thereafter. Controlled DCD involves planned withdrawal of ventilatory and organ perfusion support in the face of catastrophic illness. Uncontrolled (currently not practiced in the United States) DCD involves unexpected cardiopulmonary arrest and/or unsuccessful resuscitation, (Maastricht I, II, IV).¹³ Controlled DCD offers the patient and the family the opportunity to donate organs when criteria for brain death are not met prior to cardiac death. The procurement/transplant team plays no role in whether or when support will be withdrawn.

Brain death is usually associated with increased ICP, causing physiological responses, mainly on the cardiovascular and respiratory systems.¹⁴ Disruption of normal autonomic regulation may lead to profound vasodilation and hypotension. In turn decreased organ perfusion is injurious to potentially transplantable organs.

Cardiovascular: Increased ICP is associated with marked sympathetic stimulation (catecholamine storm), resulting in arterial hypertension, intense vasoconstriction, raised systemic vascular resistance, tachycardia and direct myocardial depression.¹⁴ Echocardiographic evidence of myocardial dysfunction is seen in 40% of brain dead donors being considered for heart donation.¹⁵ After the catecholamine storm, there is a loss of sympathetic tone causing peripheral vasodilatation and hypotension, resulting in hypoperfusion of all organs leading to significant injury that may preclude organ donation if not corrected in timely fashion.

Respiratory: Respiratory dysfunction associated with brain death will have profound effects on all other organ systems due to hypoxia. Impaired gas exchange is common in brain dead patients who have required mechanical ventilation for any length of time. Pulmonary infection and or aspiration injury frequently occur in potential organ donors. Neurogenic pulmonary edema is another cause of impaired gas exchange that may accompany brain death.¹⁶ Myocardial dysfunction may also contribute to lung dysfunction due to increases in left atrial pressure thereby potentiating pulmonary edema. Hypoxemia will further impair myocardial function leading to a precarious hemodynamic state.

Endocrine: A number of hormonal changes occur after brain death and reflect anterior and posterior pituitary failure. There is early depletion of antidiuretic hormone and development of diabetes insipidus in almost 80% of brain dead organ donors. This is characterized by inappropriate diuresis, severe hypovolemia, hyperosmolality, and hypernatremia. These changes may exacerbate neurogenic pulmonary edema and lead to tissue hypo perfusion. If not managed appropriately diabetes insipidus will have a profound effect on fluid and electrolyte balance. A rapid decline in free triiodothyronine (T3) is seen after brain stem death. Insulin levels fall after brain death, leading to a decrease in intracellular glucose concentration, the development of an energy deficit, and a shift toward anaerobic metabolism and acidosis. Significant decreases in cortisol levels occur after brain death as a result of a decreased release of its stimulating factor adrenocorticotropic hormone (ACTH) from the anterior pituitary. The administration of exogenous corticosteroids has been associated with stabilization of organ function.

Other interrelated effects of brain death include endothelial activation, systemic release of proinflammatory cytokines, complement activation and consumptive coagulopathy. Without appropriate intervention, brain death is followed by severe injury to all other organs, and circulatory collapse will usually occur within 48 hours.

Prior to the declaration of brain death, the treatment of patients with severe brain injury is directed at controlling ICP and preserving cerebral perfusion pressure in order to limit secondary brain injury. Once the diagnosis of brain death is established and a patient is recognized as a potential organ donor, treatment priorities must shift in favor of preserving the function of potentially transplantable organs. Preservation of organ function requires maintenance of adequate organ perfusion. The most common derangements requiring interventions are hypothermia, hypotension, and diabetes insipidus. Because of the profound effects on the cardiovascular system, invasive hemodynamic monitoring is essential to guide the appropriate resuscitation of brain dead patients. Central venous access should be obtained to allow measurement of volume status and to provide a reliable means of administering vasoactive drugs. Arterial access is required to facilitate continuous monitoring of blood pressure and frequent measurement of acid–base status, gas exchange, and serum biochemical parameters.

One of the strategies with proven success in increasing organ donation is utilization of aggressive donor management (ADM) protocol, by decreasing the number of donors lost as a result of cardiovascular collapse.¹⁷ The components of ADM include (Fig. 50-3): (1) early identification of potential donors, (2) intensive care unit admissions and management by a dedicated team, and (3) early and aggressive resuscitation with fluids, vasopressors and hormone therapy.

Hypovolemia is common in brain dead patients due to vasodilation and in some cases blood loss as a result of trauma or fluid loss due to diabetes insipidus. In general, patients should be resuscitated with crystalloid and appropriate blood products based on measurements of hematocrit and coagulation status. Resuscitation should be guided by frequent monitoring of central venous pressure or pulmonary capillary wedge pressure. Avoiding excessive fluid loading in donor management is associated with increased numbers of transplantable lungs¹⁸ and pancreas. Body temperature must be monitored and should be maintained above 36°C using passive warming as needed. Urine output should be maintained at 2 mL/kg/h. Renal dose dopamine (3–5 mcg/kg/min) is recommended for nearly all donors unless higher doses are required to maintain perfusion. Vasopressin should be infused to treat diabetes insipidus when present, and fluids should be adjusted on the basis of electrolyte measurements. Serum sodium and osmolarity should be kept as normal as possible. Replacement fluids should be based on measurements of serum electrolytes and urine output. Frequent serum glucose measurements are required to facilitate treatment of hyperglycemia.

Inotropic support should be introduced to support blood pressure if initial volume resuscitation fails to restore adequate perfusion pressure.¹⁹ Dopamine is usually the first agent of choice. Pure vasoconstrictors such as norepinephrine should be avoided whenever possible due to deleterious effects on myocardial, and splanchnic perfusion. Dobutamine is frequently added to increase cardiac output. If these agents are not effective at restoring hemodynamic stability, an epinephrine infusion should be initiated and titrated to the lowest dose required to achieve adequate support. The use of high doses of norepinephrine in donors is associated with increased cardiac graft dysfunction, particularly right ventricular performance, and higher early and late mortality in the recipients. Thyroxine (T4) or triiodothyronine (T3) infusions are commonly used due to their inotropic effects and potentiation of myocardial catecholamine sensitivity.²⁰

Ventilator management in potential organ donors is guided by the respiratory function of the donor. Pulmonary injury is common in brain dead patients, and all attempts should be made to preserve the possibility of lung donation. As mentioned previously, fluid overload must be avoided and infusions should be guided by measurements of central venous pressure. Chest radiographs should be obtained to assess pulmonary expansion, guide appropriate intervention to counteract atelectasis, and assess the suitability for transplantation. A nasogastric tube should be placed and kept on suction in order to minimize gastric distension and the risk of aspiration. An endotracheal tube with an internal diameter of 7.5 mm or larger should be inserted whenever possible in order to accommodate a therapeutic size fiber optic bronchoscope. This will assist in the evaluation of potential lung donation and will facilitate clearing secretions to optimize lung expansion. Excessive mean airway pressures should be avoided. Tidal volumes and physiologic levels of positive end-expiratory pressures (PEEP) should be maintained to provide adequate lung expansion and minimize atelectasis. High concentrations of inspired oxygen are injurious to the lungs and should be avoided. The inspired oxygen concentration should be titrated to maintain an oxygen saturation of 95%. In patients with significant pulmonary injury, lung donation is unlikely; therefore, increased levels of PEEP and higher inspired oxygen concentrations may be required.

The actual process of multiorgan procurement occurs in the operating room environment under the usual sterile conditions. Representatives of the local OPO will coordinate the use of the operating room with various transplant procurement teams involved with a particular donor. Frequently, this procedure may involve several teams whose members are operating together for the first time. In addition, the initial phases of the recipient operations for heart and lung recipients are commonly carried out simultaneously with the donor procurement procedure in order to minimize graft ischemia time.

An anesthesiologist is required to provide physiologic support to the donor during the procurement procedure. The donor patient is prepped and draped to allow an incision from the sternal notch to the pubis. In this manner, the thoracic and abdominal organs can be evaluated and procured simultaneously. In all cases, the final determination of organ suitability for transplantation is made after visual inspection and manual palpation of the organ and other viscera to rule out any malignancy. Biopsy of any suspicious lesions should be performed, and pathologic evaluation of frozen sections must be confirmed before the recipient transplant operation is initiated. Similarly, biopsies of liver and kidneys may be required to evaluate the quality of organs in some donors.

In case of brain dead donors, the intended organs are prepared for rapid removal after exsanguination of the patient. For this purpose, the important vascular structures of the respective organs are identified and the organs are mobilized. The patient is systemically anticoagulated with a large dose of heparin. Appropriate vascular cannulae are inserted in the abdominal and thoracic vessels to allow rapid flushing of the organs being procured. There are various preservation solutions in use and vary according to the organ being procured and the preference of the procuring institution. All preservation solutions are kept at approximately 4°C because hypothermia is a key element of organ preservation. When all members of the procuring teams are prepared the superior vena cava, ascending aorta, and the supraceliac aorta are clamped. The inferior vena cava is transected at the cavo-atrial junction and blood is suctioned from the open inferior vena cava exsanguinating the patient. The left atrium is vented in order to prevent left ventricular distension and back pressure on the pulmonary vascular bed. Preservation fluids are infused through the previously placed cannulas flushing the procured organs of blood and rapidly lowering their temperature. Topical ice is applied augmenting rapid cooling. Thereafter, the heart and lungs are usually removed first. Donor hepatectomy is then carried out followed by removal of the kidneys. Variations in this sequence are required when the pancreas and or small bowel are also procured. The iliac vessels and occasionally segments of the descending thoracic aorta are then removed to provide additional vascular conduits that are sometimes necessary for complex vascular reconstructions at the time of organ implantation. All organs are inspected on the back table to ensure that no surgical damage has occurred. Finally, the organs are placed in sterile containers containing cold preservation solution. The containers are then packed in ice in preparation for transport to the location where transplantation will occur. Once all solid organs are removed any additional tissues approved for donation are removed.

In case of procurement from donation after cardiac death (DCD) donors, hospitals have their own protocols for withdrawal of life support and declaration of cardiac death. In principal, the withdrawal of life support occurs in the operating room. Heparin is administered, prior to withdrawal of support, except in the rare case when it might be expected to hasten death and/or is prohibited per local procurement protocol. Morphine and/or other analgesics may be given at the discretion of the patient’s treating care team if the purpose is to minimize discomfort according to accepted end-of-life protocols. Procurement team members do not participate in decisions regarding the use of such agents and/or declaration of death. Members of the procurement team are not present in the operating room at the time of withdrawal of support and until the declaration of death. During this period the OPO coordinators document hemodynamic measurements every minute. After cessation of cardiorespiratory function, patient’s treating physician declares death. Subsequently, a waiting period is observed prior to initiation of procurement to ensure that cardiac activity does not resume. After this waiting period, the procuring teams rapidly enter abdominal and thoracic cavities and cannulate the respective blood vessels for flushing the organs with preservation fluid. Following this, the procurement proceeds similar to that in the brain dead donors. Premortem cannulation of femoral artery and femoral vein prior to withdrawal of support, when performed decreases the rush inherent with the rapid recovery technique and may decrease warm ischemia time. If such patient will not been declared dead within the time frame stipulated by the local procurement protocol (usually 60 minutes), then the donation is aborted and the patient is returned to the intensive care unit for comfort care.

Some centers use premortem cannulation in conjunction with postmortem ECMO to restore the flow of warm oxygenated blood to the intra-abdominal organs during the interval between death and organ procurement, possibly improving graft function.²²

Organ transplantation benefits thousands of people every year in the United States. However, there is a critical shortage of organs available for lifesaving transplantation with no increase in the numbers of deceased donors in the recent years. A significant number of deceased donors in the United States are trauma victims. Therefore, health care providers who care for trauma patients will continue to play an important role in the identification and critical care management of potential organ donors. It is imperative that such personnel is aware of critical steps involved in organ donation and advanced protocols in management of such patients.